State of the Art

Excellence in Dental Esthetics: A Multidisciplinary Challenge

Achieving Excellence inSmile Rehabilitation

Using Ultraconservative EstheticTreatment:
A Multidisciplinary Vision

Victor Grover Rene Clavijo, DDS, MS, PhD 1

Paulo Fernando Mesquita de Carvalho, DDS, MS 2

Robert Carvalho da Silva, DDS, MS, PhD 2

Julio Cesar Joly, DDS, MS, PhD 2

Luis Alves Ferreira, CDT

Victor Humberto Orbegoso Flores, DDS, MS, PhD 4

T
oday, esthetic restorative dentistry can offer smile reha-
bilitations using a conservative approach with minimal re-
moval of sound dental structures. The aim of this article is
to demonstrate a multidisciplinary, ultraconservative method of
restoring the harmony of the smile.

CASE REPORT
The patient was extremely embarrassed of her smile, resulting in
shyness and minimal social interaction. The initial clinical exam
revealed diastema, congenitally missing maxillary lateral incisors
with the canines located in the lateral incisor positions, and the
primary maxillary canines still located in their original positions

also malocclusion.1 Therefore, a multidisciplinary treatment was

suggested to restore both esthetics and function.2

1
Professor, Advanced Program in Implantology and Restorative Dentistry,
ImplantePerio Institute, São Paulo, Brazil.

2
Director, Advanced Program in Implantology, ImplantePerio Institute, São
Paulo, Brazil.

4
Associate Professor, Restorative Dentistry, Preventive, and Fixed
Prosthodontics, Federal University of Alfenas School of Dentistry, Alfenas,
Minas Gerais, Brazil.

Correspondence to: Dr Victor Clavijo, Rua Cerqueira Cesar, 1078 Indaiatuba,

São Paulo, Brazil 13330-005. Email: clavijovictor@yahoo.com.br QDT 2012 3
 CLAVIJO ET AL

1a 1b

1c

1d 1e

Figs 1a to 1e  Preoperative situation showing esthetic deficiencies due to diastema, canine location, and presence of pri-
mary teeth. Note the discrepancy in the position of the gingival margin.

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 Achieving Excellence in Smile Rehabilitation Using Ultraconservative Esthetic Treatment
Phase 1: Planning
All dental professionals involved in the treatment (or-
thodontist, periodontist, master ceramist, and opera-
tive dentist) evaluated the clinical case individually to
decide which noninvasive procedures were indicated.
Next, the four professionals discussed the prognosis
and limitations of the case. The master ceramist per-
formed a diagnostic wax-up to provide a model of the
multidisciplinary treatment. After patient approval,
the conservative treatment was then split into three
restorative phases: orthodontic, surgical, and restor-
ative.
Phase 2: Orthodontics (Figs 2 to 6)
The orthodontic phase began with the analysis of
craniofacial growth, radiographs, and study casts. Pri-
mary maxillary canines were extracted, and a fixed
orthodontic appliance was used to close the diastema
between the maxillary central incisors and redistribute
the interdental spaces for esthetic rehabilitation. The
orthodontic treatment used the following parameters
for evaluation: sagittal relationship between the den-
tal arches; posterior occlusion; location, shape, and
size of the canines; amount of remaining interdental
space; and profile and facial skeletal pattern of the pa-
tient.3 After orthodontic treatment was finalized, the
orthodontic brackets were removed and a removable
appliance was used to replace the missing maxillary
lateral incisors.
Phase 3: Surgical (Fig 7)
The surgical phase was initiated with esthetic flap sur-
gery to reposition the zenith of the maxillary canines
and central incisors. On the same day, open full-flap
envelope surgery allowed the placement of two im-
plants to replace the congenitally missing maxillary
lateral incisors (3.3 × 14 mm, Straumann Bone Level
Narrow CrossFit, Straumann, Basel, Switzerland). After
implant placement, conjunctive grafts were performed
to increase the gingival volume, and healing caps were
placed. These procedures were necessary to restore
the harmony of the pink (gingival) and white (dental)
architecture.
Phase 4: Restorative (Figs 8 to 36)
After a period of healing and osseointegration, uncov-
ering surgery was performed. The transfer copings were
then positioned, and a polyvinyl siloxane (PVS) impres-
sion was made to fabricate the working cast. Zirconia
abutments and provisional crowns were fabricated to
shape the gingival margins to the desired contour.
After the gingival tissues were remodeled and con-
toured, acrylic resin impression copings (Duralay, Reli-
ance Dental, Worth, Illinois, USA) were fabricated for
the implant abutments before the final pickup impres-
sion was taken using PVS. Before the impressions pro-
cedures, an interocclusal bite registration was taken
and the shade was selected.
Two lithium disilicate all-ceramic crowns (IPS e.max
Ceram, Ivoclar Vivadent, Schaan, Liechtenstein) were
made for the implants, and two feldspathic ceramic
fragments (IPS d.Sign, Ivoclar Vivadent) were fabri-
cated using the refractory die technique to close the
diastema between the maxillary central incisors.
All restorations were checked for fit, marginal adap-
tation, and interproximal contacts. The final shade was
evaluated using glycerin-based try-in paste (Variolink
Try-in, Ivoclar Vivadent), which resulted in the selection
of clear translucent resin cement. All restorations were
adhesively cemented. The fragments were etched with
hydrofluoric acid for 90 seconds, rinsed, and dried.
To remove any ceramic debris, additional etching was
carried out with 35% phosphoric acid for 30 seconds.
All fragments were silanated (Monobond, Ivoclar Viva-
dent). The lithium disilicate crowns were also processed
as described above, except that the hydrofluoric acid
etching was performed for only 20 seconds.
The ceramic fragments were simultaneously bond-
ed to etched enamel using light-polymerized dental
adhesive (Excite, Ivoclar Vivadent) and a clear translu-
cent light-polymerized resin cement (Variolink II, Ivo-
clar Vivadent). Facial and palatal ceramic overcontour-
ing was removed with a high-speed fine diamond bur,
followed by polishing with intraoral ceramic finishing
and polishing points. After cementation of the ceramic
fragments, the lithium disilicate ceramic crowns were
adhesively cemented to the zirconia implant abut-
ment. The zirconia abutments were silanated (Mono-
bond Plus), and dual-cured resin cement was used for
bonding (Variolink II). Occlusion was checked, and the
patient was dismissed.
QDT 2012 5
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2a 2b

Fig 2a  Orthodontic appliance in place.

Fig 2b  After 24 months, note the recov-

ery of space required for prosthetic reha-
bilitation of the maxillary lateral incisors.

Figs 3  Facial view after completion of

orthodontic treatment.

Figs 4a to 4d  Extraoral views of the

smile after orthodontic treatment.

4a 4b

4c 4d
6 QDT 2011
 Excellence in Dental Esthetics: A Multidisciplinary Challenge

5a 5b 5c

5d 5e

Figs 5a to 5e  Intraoral views of the maxillary anterior teeth after orthodontic
treatment. Note the asymmetry of the gingival margins and the diastema between
the central incisors.

6a

6b 6c

Figs 6a to 6c  Incisal views of the maxillary anterior teeth.

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7a 7b

Figs 7a and 7b  Clinical appearance 2 months after implant placement at the maxillary lateral incisor sites.

8a 8b

8c 8d 8e

Figs 8a and 8b  A minimally invasive surgical procedure was performed to expose the implants.

Figs 8c to 8e  Placement of the transfer copings.

9a 9b

8 Figs
QDT 9a and 9b  Placement of the transfer guides.
2011
 Excellence in Dental Esthetics: A Multidisciplinary Challenge

10a 10b

10c 10d

Figs 10a to 10d  PVS impression procedure.

Fig 11a  Transfer copings and analogs. Fig 11b  Insertion of the transfers into Fig 11c  Placement of the transfers and
the analogs. analogs on transfer guides captured by
the mold.

Fig 12a  Machined pillar and prefabri-

cated zirconia abutment [Au: “pillar” =
implant?].

Fig 12b  Phosphoric acid applied for 60

seconds.

12a 12b

12c 12d 12e

Figs 12c and 12d  Application of Metal-Zirconia Primer (Ivoclar Vivadent).

Fig 12e  Application of the adhesive (Multilink, Ivoclar Vivadent) into the zirconia abutment. QDT 2012 9
 RUTTEN/GAMBORENA/RUTTEN

13a 13b

Fig 13a  Cementation of the abutment

(Multilink).

Fig 13b  Removal of excess cement.

Fig 13c  Finishing of the bonded inter-

face.

Fig 13d  Abutments after cementation

(Luiz Alves Ferreira, CDT).

13c 13d

14a 14b 14c

Figs 14a to 14c  Provisional restora-

tions and abutments.

Fig 14d  Abutments on the cast.

Fig 14e  Acrylic resin guide for abut-

ment placement.

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14d 2011 14e
 Excellence in Dental Esthetics: A Multidisciplinary Challenge

15a 15b 15c

Fig 15a  Removal of the healing cap.

Figs 15b to 15e  Guided insertion of

the abutment.

Fig 16a  Soft composite resin sealing of

the screw access hole.

Fig 16b  Light polymerization.

Fig 16c  PVS impression of the abut-

ment. 15d 15e

16a 16b 16c

17a

17b 17c

Figs 17a to 17c  Provisional restorations 3 months after placement. QDT 2012 11
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18a 18b

18c 18d

Fig 18a  After healing, note the condition of the soft tissue prior to final impression procedures.

Figs 18b to 18d  Impression copings.

19a 19b

19c 19d

Figs 19a to 19d  Shade selection: (a) VITA Classical Shade Guide (VITA Zahnfabrik, Bad Säckingen, Germany)
with different hues, chromas, and values; (b) same image in grayscale; (c) detail view of the central incisors; (d)
12 QDT 2011
detail view of the central incisors with increased saturation.
 Excellence in Dental Esthetics: A Multidisciplinary Challenge

20a 20b

20c

20d 20e

Fig 20a  Clinical try-in of the ceramic fragments (Luiz Alves Ferreira, CDT).

Figs 20b and 20c  Interproximal contact verification.

Fig 20d  Positioning of the ceramic fragments.

Fig 20e  The try-in procedure (Variolink II) resulted in the selection of translucent resin cement.

Fig 21a  Ceramic fragments prior to Fig 21b  Hydrofluoric acid etching for Fig 21c  Intaglio aspect after hydroflu-
bonding. 90 seconds. oric acid etching. QDT 2012 13
 Fig 22a  Application of phosphoric
RUTTEN/GAMBORENA/RUTTEN acid for 30 seconds to remove etched
ceramic debris.

Fig 22b  Ceramic fragments after phos-

phoric acid cleaning.

22a 22b

Fig 23a  Application of silane for 60

seconds (Monobond).

Fig 23b  Application of bonding agent

(Excite).

23a 23b

24a 24b

24c 24d

Fig 24a  Prophylaxis of enamel surfaces before bonding with pumice slurry.

Fig 24b  Enamel etching for 30 seconds.

Fig 24c  Application of a two-step etch-and-rinse adhesive (Excite).

14 QDT24d 
Fig 2011Evaporation of the solvent and thinning of the bonding agent.
Fig 25a  Ceramic fragments bonded with transparent resin cement (Variolink II)
before light polymerization. Excellence in Dental Esthetics: A Multidisciplinary Challenge

Figs 25b to 25d  Removal of excess resin cement with (b) an artist brush, (c) cot-
ton pellets, and (d) dental floss.

Fig 25e  Bonded ceramic fragments were light polymerized for 60 seconds per
surface.

25a

25b 25c 25d

25e

Fig 26a  Demarcation of the line angles and margins.

Figs 26b and 26c  The ceramic/enamel margins were finished with a fine dia-
mond bur to remove ceramic overcontouring.

Fig 26d  Intraoral ceramic polishing cups were used to polish the margins.

Fig 26e  Clinical appearance immediately after cementation, finishing, and pol-
ishing of the ceramic fragments.

26a

26b 26c 26d

26e QDT 2012 15

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27a 27b 27c

Figs 27a to 27c  Lithium disilicate all-ceramic crowns for the maxillary lateral incisors (Luiz Alves Ferreira, CDT).

Figs 28a and 28b  Intaglio etching with hydrofluoric acid for 20 seconds, fol- Fig 28c  Application of the bonding
lowed by cleaning with phosphoric acid for 30 seconds and silane application. agent (Excite) before adhesive cemen-
tation with dual-cured transparent resin
cement (Variolink II).

Fig 29b  Transillumination of the crowns and ceramic fragments.

Fig 29a  Intraoral view after cementation.

30a 30b

Figs 30a and 30b  Close-up views of the maxillary lateral incisors showing adequate gingival contours and emergence profile
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16 around 2011
implants.
 Excellence in Dental Esthetics: A Multidisciplinary Challenge

31a 31b

31c Figs 31a to 31c  Clinical follow-up after 16 months.

32a 32b
Fig 32a and 32b  Proper balance of shade, contour, form, and occlusion was obtained. QDT 2012 17
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33a 33b

34

35
18 QDT 2011 Figs 33 to 36  Final result.
 Achieving Excellence in Smile Rehabilitation Using Ultraconservative Esthetic Treatment

36 QDT 2012 19
 CLAVIJO ET AL

Discussion Conclusion
Although alternative treatment options were available This article presented the successful multidisciplinary
for this clinical case, the chosen technique guaran- treatment of a patient with severe esthetic and func-
teed the preservation of sound dentition. Orthodontic tional deficiencies. Multidisciplinary treatment plan-
mesialization of the teeth with intrusion and extrusion ning can provide patients with high-quality noninva-
could also have been performed; however, the final sive treatment that results in superior esthetics.
esthetic outcome would not be the most desirable.4
Conversely, a mesiodistal and facial-palatal alignment
of the maxillary canines is completely different from
that of the maxillary lateral incisors, which hinders smile Acknowledgments
esthetics and may contribute to bite overload during
The authors thank Luis Alves Ferreira, CDT, and Dudu Medeiros for
chewing.3 Correct positioning of teeth and maxillary
the facial photography of the patient.
bone allows for better lip support and smile esthet-
ics.2 The distalization of the maxillary canines ensured
restoration of anterior guidance and occlusal function
along with the esthetic rehabilitation.4,5
Treatment planning is the key to treatment success. References
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es, no reduction or preparation was necessary, and the ment in the adolescent patient. Am J Orthod Dentofacial Or-
thop 2002;121:594–595.
dental structures remained intact. The diastema was
2. Davis NC. Smile design. Dent Clin North Am 2007;51:299–318.
closed using an additive approach via the adhesive ce- 3. Rosa M, Zachrisson BU. Integrating esthetic dentistry and space
mentation of ceramic fragments.6,7 Recent advances in closure in patients with missing maxillary lateral incisors. J Clin
Orthod 2001;34:221–233.
bonding techniques for both teeth and ceramic guar-
4. Oquendo A, Brea L, David S. Diastema: Correction of excessive
antee the clinical success of this type of restoration. spaces in the esthetic zone. Dent Clin North Am 2011;55:265–
After adhesive cementation of the ceramic frag- 281.
ments, minimal facial or palatal overcontouring was 5. Okeson JP. Management of Temporomandibular Disorders and
Occlusion, ed 5. St Louis: Mosby, 2003.
observed. This overcontouring must be removed by
6. Rads MG. Minimum thickness anterior porcelain restorations.
finishing and polishing at the ceramic-enamel inter- Dent Clin North Am 2011;55:353–370.
face. High-speed fine diamond burs under copious 7. de Andrade OS, Kina S, Hirata R. Concepts for an ultraconser-
vative approach to indirect anterior restorations. Quintessence
water-cooling can be used to adjust the ceramic inter-
Dent Technol 2011;34:103–119.
face. Next, intraoral ceramic polishing rubber points
were used to minimize roughness and restore smooth-
ness until achieving a surface analogous to the glazed
ceramic.6 Ceramic fragments bonded to unprepared
enamel present very few disadvantages; nonetheless,
communication between the clinician and technician is
fundamental to obtain an acceptable result.6

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